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  The International Liver Congress™
EASL - European Association for the
Study of the Liver
June 23-26 2021
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Liver Impairment With COVID-19 Tied
to More Severe Coronavirus Disease

  EASL International Liver Congress, June 23-26, 2021
Mark Mascolini
Analysis of 595 people admitted to the hospital in Barcelona with COVID-19 linked liver function test (LFT) abnormalities to more severe COVID-19 and to male gender [1]. Clinicians could usually discern an underlying cause of abnormal LFTs during in-hospital follow-up, usually fatty liver disease, but abnormal follow-up LFTs were not related to abnormal admission LFTs
Prior research documented LFT abnormalities in 21% to 64% of people with SARS-CoV-2 infection, according to researchers at the Hospital del Mar and other Barcelona centers who conducted this study. Suspected causes of abnormal LFTs in this population include a severe inflammatory response to the coronavirus, drug-induced liver injury, hypoxic injury, and direct cytopathic effects. So far, though, research has yielded no data on evolution of LFTs and liver damage after acute COVID-19 resolves.
The Barcelona team aimed to identify clinical predictors of abnormal LFTs in people admitted to the hospital with SARS-CoV-2 infection and to chart liver outcomes after acute COVID-19 resolves. The researchers defined abnormal LFTs by total bilirubin, aspartate aminotransferase (AST), and alanine aminotransferase (ALT), according to Common Terminology Criteria for Adverse Events 4.0. Severe COVID-19 meant a P/F ratio (arterial pO2 divided by FIO2) below 200 [2] and/or intensive care unit (ICU) admission for organ dysfunction.
This observational study included the first consecutive 600 people with COVID-19 admitted to the Hospital del Mar, a Barcelona tertiary-care center. Excluding 5 people with bili1ary pathology, liver cancer, or known pharmacologic liver toxicity, the researchers focused on 595 inpatients, 366 (61.5%) with admission LFTs and 229 without admission LFTs. Sixty-one people (10%) died in the hospital, and 534 were discharged. Among the 534 survivors admitted to the hospital from February through April, 2020, 153 (29%) had prospective follow-up from October 2020 through April 2021.
Of the 595 initial participants, 60.5% were men and median age stood at 62 years. While 41% had hypertension, 17% had diabetes, 42% were obese, 38% were overweight, 4% had harmful alcohol use, and only 0.8% (5 people) had cirrhosis. Records showed that 241 people (40.5%) had a worst P/F ratio below 200 [2], 16% got admitted to the ICU, and 42% had severe COVID-19 as defined above. More than half of these 595 people (61.5%) had abnormal LFTs during their hospital stay.
People with versus without abnormal (grade 1-4) LFTs were more likely to be men (69.4% vs 46.3%, P < 0.001), had a lower (worse) P/F ratio at admission (328 vs 360, P < 0.001), and were more likely to have an admission P/F ratio below 200 (13.4% vs 2.3%, P < 0.001). Multivariate analysis determined that an admission P/F ratio below 200 boosted odds of abnormal LFTs more than 5-fold (odds ratio [OR] 5.47, 95% confidence interval [CI] 1.79 to 16.73, P = 0.003). People with abnormal LFTs also had more than 5-fold higher odds of ferritin at or above 1000 ng/mL (OR 5.27, 95% CI 3.19 to 8.70, P < 0.001) and were twice as likely to be male (OR 1.98, 95% CI 1.28 to 3.06, P = 0.002).
From admission to follow-up, the number of people with abnormal LFTs fell from 92 (60.1% of 153 people in the prospective analysis) to 16 (10.5% of 153). People with abnormal LFTs during follow-up were marginally more likely to be younger (median 53 vs 65, P = 0.053) and more likely to be from South or Central America (50.0% vs 18.2% with normal LFTs, P = 0.008). In this follow-up group, people with abnormal LFTs had a significantly higher liver stiffness measure (LSM) than those with normal LFTs (6.0 vs 4.4 kPa, P < 0.001) and significantly higher controlled attenuation parameter (CAP, a measure of hepatic steatosis) (334 vs 276 db/m, P = 0.003).
The researchers stressed that having abnormal LFTs at follow-up was not related to abnormal LFTs at hospital admission. Most people with abnormal LFTs in the follow-up group had a discernible underlying cause, usually fatty liver disease.
At hospital admission, the Barcelona team concluded, abnormal LFTs are related to more severe COVID-19 (P/F ratio below 200 and ferritin above 1000 ng/mL) and to male gender.
1. Canillas L, Pagano G, Broquetas T, et al. Factors related to liver impairment during SARS-CoV-2 infection. EASL International Liver Congress, June 23-26, 2021. Abstract OS-1921.
2. A P/F ratio below 300 indicates mild acute respiratory distress syndrome (ARDS), below 200 means moderate ARDS, and below 100 means severe ARDS. P/F Ratio Calculations-Supplement to CDI Pocket Guide. https://pinsonandtang.com